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Management of Chronic Heart Failure in General Practice
Paul SmithConsultant CardiologistBradford Royal Infirmary
• Prevalence and impact
• Assessment of heart failure patient
• Aetiology and Pathophysiology
• Modern management of heart failure
• Monitoring and chronic disease management
• When to refer for Specialist advice
• Brief overview of cardiac resynchronisation therapy
Presentation Overview
• Heart failure effects 1-2% of adult UK population
• Incidence of 5-10 cases per 1000 population per year
The Incidence of Heart Failure
0
2
4
6
8
10
12
14
16
18
25-34 35-44 45-54 55-64 65-74 75-84 85+ Total
Inci
denc
e/10
00 p
opul
atio
n/ye
ar
MenWomen
British Heart Foundation, 2002
Heart Failure is Bad News!
British Heart Foundation, 2002
0 20 40 60 80 100
Melanoma
Breast
Uterus
Bladder
Prostate
NHL
Colon
Heart failure
Ovarian
Kidney
Leukaemia
Stomach
Oesophagus
Lung
Pancreas
One year survival rate (%)
Heart Failure is Costly• 5% of all medical admissions
• £716M per annum
• 1.8% of total NHS budget
• 70% due to hospitalisations
• Heart failure “the growing epidemic”
• Admissions predicted to rise by 50% over the next 25 years
British Heart Foundation, 2002
Chronic Heart Failure
“Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the pumping ability of the heart”
Stages in the Development of Heart Failure
Stage Patient Description
A
B
C
D Refractory end-stage HF
Marked symptoms at rest despite maximal medical therapy (e.g., those who are recurrently hospitalised or cannot be safely discharged from hospital without specialised interventions)
High risk for developing heart failure (HF)
Coronary artery diseaseHypertensionDiabetes mellitus, obesityFamily history of cardiomyopathy
Asymptomatic HF
Previous myocardial infarctionLeft ventricular systolic dysfunctionAsymptomatic valvular disease
Symptomatic HFKnown structural heart diseaseShortness of breath and fatigueReduced exercise tolerance
Increasing severity
Diagnosing Heart Failure
• Shortness of breath on exertion
• Fatigue (exercise intolerance)
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Fluid retention
…symptoms are non-specific and present in many other conditions!
Masquerading as Heart Failure• Obesity
• Venous insufficiency
• Drug induced ankle swelling
• Chest disease - pulmonary embolic disease
• Angina
• Hypoalbuminaemia
• Renal or hepatic disease
• Depression/anxiety
• Severe anaemia or thyroid disease
• Bilateral renal artery stenosis
Diagnosing Heart Failure• The most specific signs are:
Laterally displaced apex beat
Elevated JVP
Third heart sound
• Less specific signs include:
Basal crackles
Peripheral oedema
Hepatic engorgement
Tachycardia
….signs are insensitive and may not be present!
• FBC, U+E, LFT, TFT, glucose, lipids
• NT-pro-BNP (if available)
• Abnormal in over 90%• LBBB, Q waves• LVH• AF• ST/T wave changes• VE, NSVT
Heart Failure - baseline investigations
Heart Failure Diagnostic Pathway
No investigation for heart failure has 100% negative predictive value. If clinical suspicion remains high then specialist referral recommended
• Single most effective tool in the diagnosis of heart failure
• Provides information on structure and function of cardiac chambers, valves and pericardium
• EF useful measure of LV systolic dysfunction
• Reports should provide information in clinical context
• Other imaging modality may need to be considered for obese and chronic lung disease
Echocardiography
LVF/CCF• Heart failure is not a complete diagnosis
• Requires more than stating whether syndrome present or not
• The following should be considered:
Underlying cardiac condition
Severity of the syndrome
Estimation of prognosis
Precipitating and exacerbating factors
Co-morbidity
Aetiology
Comorbidity Comments
COPD/Asthma β Blockers are contraindicated in reversible airways disease.
Renal failure (creat>200μmol/l)
ACEi and ARBs may be contraindicated
Thyroid Severe thyroid disease may cause/precipitate HF
PVD High index of suspicion of RAS
Urinary frequency α blockers may cause fluid retention and hypotension. Diuretics may not be tolerated.
Gout Exacerbated by diuretics. Avoid NSAID’s.
Impact of Comorbidities on Heart Failure Treatment
NYHA ClassificationNYHA functional class
Definition Diagnosed HF cases %
0
69
15
16
NYHA 1No limitation: ordinary physical exercise does not cause dyspnoea or fatigue.
NYHA 2Slight limitation of physical activity. Patients are comfortable at rest. Ordinary physical activity results in breathlessness, fatigue, palpitations or angina (symptomatically mild heart failure).
NYHA 3Marked limitation of physical activity: comfortable at rest but dyspnoea washing and dressing, or walking from room to room (symptomatically moderate heart failure).
NYHA 4Severe limitation of physical activity: dyspnoea at rest, with increased symptoms with any level of physical activity (symptomatically severe heart failure).
British Heart Foundation, 2002
IHD
Aetiology of Heart Failure
Valvular heart disease
Hypertensive heart disease
Dilated CMP (idiopathic, viral,
alcohol, chemotherapy)
95%
Rare causes:
• postpartum
• tachy-cardiomyopathy
• infiltrative -haemochromatosis, amyloidosis, sarcoidosis
• muscle disorders (myotonicdystrophy, muscular dystrophy)
• infective (HIV)
• inherited disorders
• endocrine (phaeo, hyperthyroid, acromegaly)
Compensatory MechanismsBody “sensing” poor perfusion as hypovolaemiaMechanisms evolved to save our ancestors
Response Short term Effects Long term Effects
Salt and water retention
Augments preload Pulmonary congestion/ oedema in proximal bed
Vasoconstriction Maintains BP for perfusion of vital organs
Exacerbates pump dysfunction (inc. afterload) increases cardiac energy expenditure
Sympathetic Stimulation
Increases HR and ejection fractionPeripheral vasoconstriction
Increases energy expenditure and risk of sudden arrhythmia and death *
MAJOR CAUSE OF POOR LONG TERM OUTCOMES
Cardiac injury
RAAS
Pump FailureReduced CO and Stroke volume
SNS
Renal Perfusion Tissue Perfusion
Neuro-Hormonal Activation
vasoconstrictionsalt and water retention
+ve ino/chrontropicBeta-blockersACE-I, ARB,
Aldos. antag
Progressive pump failure & LV Remodeling
Heart Failure Vicious Cycle
Heart Failure Management Timeline
Early Years
1980’s
1990’s
2000’s
? 2010’s
Non-pharmacological era:
Bed rest, inactivity, fluid restriction, fluid removal, (digitalis & diuretics)
Pharmacological era:
Digitalis, diuretics, inotropes
1986 First vasodilator HF trial (V-HeFT-1) Nitrates/hydralazine
Neurohormonal intervention:
ACEi, beta-blockers, aldosterone antagonists
Device era:
CRT, ICD’s, LVAD’s
Cellular/Genetic era:
Gene therapies, cell regeneration, xenotransplantation
Modern Management of Heart Failure
Aims of therapy in heart failure:Improve life expectancy
Improve quality of life
The relative importance of these varies:between patients
over time
Modern Management of Heart Failure• Multidisciplinary approach
• Lifestyle measures
Patient education/supportWeight control (volume status)Dietary modification (salt, alcohol)Reducing fluid intakeSmoking cessationExercise and rehabilitationInfluenza vaccination
• Pharmacological therapy – what to use and what to avoid!
• Devices and surgery
Drug Therapy in Heart FailureDiureticsNeurohormonal antagonists
ACE inhibitorsBeta blockersAldosterone antagonistsAngiotensin receptor blockers
DigoxinOther drugs
Nitrates/hydralazineAmiodaroneWarfarinAspirin
Treatment Algorithm for the Management of CHF
NICE, 2003
Digoxin
• Oldest established drug treatment for HF
• Extract of Foxglove (Digitalis purpurea)
• 1785 William Withering
• Narrow therapeutic window
• Arrhythmias and GI side effects common
DIG Trial 1997 (Digoxin 250μg od.)
No mortality benefit
Significant reduction in hospitalisations due to worsening HF
Digoxin
• Digoxin is recommended for:
i. Worsening or severe heart failure due to LV systolic dysfunction despite ACE inhibitor, beta-blocker and diuretic therapy
ii. Patients with AF and any degree of heart failure
NICE, 2003
Diuretics• 1920 Organomercurial diuretics first used• 1958 Thiazide diuretics introduced• Useful in the acute setting and in the overloaded patient
• Rapid relief of congestive symptoms
• Exacerbate RAA system due to diuresis and natriuresis
• No evidence for mortality benefit, no effect on disease progression
• Need to up and down titrate according to symptoms
“ Diuretics should be routinely used for the relief of congestive symptoms and fluid overload in patients with heart failure”
ACE Inhibitors (1)
• Review of data from 5 RCT’s
• Compared with placebo. ACEi reduce
Mortality (p<0.0001)
Readmission (p<0.0001)
Reinfarction (p<0.0001)
• Benefit occurs early (30 days)
• First ACE inhibitor - Captopril synthesised in 1977
• Undisputable evidence of reduction in mortality in chronic HF
Flather et al., Lancet 2000
ACE Inhibitors (2)….. in symptomatic heart failure patients:CONSENSUS 1987 (First ACEi trial - Enalapril 20mg bd)SOLVD 1990ATLAS 1999 (High v Low dose Lisinopril)
….in post infarct heart failure:SAVE 1991 (Captopril 50mg tds)AIRE 1993 (Ramipril 5mg bd)TRACE 1995 (Trandolapril 4mg od)
….and in asymptomatic patients with LV dysfunction:SOLVD 1990 (prevention arm)TRACE 1995SAVE 1991
ACE inhibitors (3)
“all patients with heart failure due to LV systolic dysfunction should be considered for treatment with an ACEi”
• start with low dose
• aim for trial target dose or highest tolerated dose
• Remember, some ACEi is better than none
• Symptomatic low BP (stop other vasodilators ± diuretics)
• Monitor creatinine and electrolytes
• Rise in creatinine of 30% is probably acceptable
Aldosterone
Na/H20
oedema
Impaired ANS
↓ HRV
↓ BRS
Myocardial & Vascular fibrosis
Myocyte necrosis & scarring
→ LV remodeling
Endothelial dysfunction
(NO)
Heart Failure Progression and Cardiac Death
Aldosterone & Heart Failure
N Engl J Med 1999;341:709-17
Spironolactone
• RALES trial 1999 (25mg od)
• NYHA III/IV on ACEi, diuretic ±digoxin
30% RRR in death
35% RRR in hospitalisation
Aldosterone Antagonists
2 currently available:
Spironolactone
Eplerenone
NICE Recommendations on Spironolactone
“Heart failure patients who remain moderate-severely symptomatic despite OMT should be prescribed spironolactone at a dose of 12.5 - 50mg daily”
• Symptom improvement in weeks - months
• Monitor Potassium & Creatinine
• If hyperkalaemia occurs, halve dose
• S.E. Breast discomfort +/- gynaecomastia
Primary End Points: • All-cause mortality• CV mortality/CV hospitalisation*
Secondary End Points: • CV mortality• All-cause mortality/all-cause hospitalisations• CV hospitalisations
Placebon = 3313
1012 Deaths
Randomise 3–14 Days Post–AMI
Eplerenone 25–50 mg od
n = 3319
AMI, LVEF ≤ 40%, Clinical HF, Standard Therapy
*CV hospitalisation = hospitalisation for heart failure, MI, stroke, or ventricular arrhythmia
Pitt B et al. Cardiovasc Drugs and Therapy 2001; 15: 79-87
EPHESUS
Aldosterone antagonist for heart failure post MI
All-Cause Mortality
Months Since Randomisation
Cumulative Incidence (%)
Placebo
Eplerenone
22
0
2
20
16
18
14
12
10
8
6
4
RR = 0.85 (95% CI, 0.75-0.96) P = 0.008
3633302724211815129630
Pitt B et al. N Eng J Med 2003; 348: 1309-1321
EPHESUS
CV Mortality/Hospitalisation
Months Since Randomisation
40
0
35
25
30
20
15
10
5
3633302724211815129630
Placebo
Eplerenone
RR = 0.87 (95% CI , 0.79 - 0.95)P = 0.002
Pitt B et al. N Eng J Med 2003; 348: 1309-1321
EPHESUS
Cumulative Incidence (%)
• ACE inhibitors and ARB’s do not adequately suppress aldosterone levels, leading to aldosterone ‘escape’
• When added to conventional therapy in HF aldosterone receptor antagonists are cardioprotective
↓ all-cause mortality ↓ cardiac mortality ↓ hospitalisations for heart failure
• These benefits are in addition to those conferred by ACE inhibitors
Summary: Aldosterone antagonists
Aldosterone antagonists: -- Spironolactone or Eplerenone?
• Licensed for different indications
• No evidence for beneficial effect of Spironolactone in heart failure post MI
• No evidence for beneficial effect of Eplerenone in CHF
• 10% incidence of gynaecomastia with Spironolactone
• Similar problems with hyperkalaemia
• Eplerenone significantly more expensive
Beta Blockers in Heart Failure• ß blockers protect against plasma Norepinephrine/Epinephrine
• More patients in trials with beta-blockers than ACEi
Name Drug Year n
MDC Metoprolol tartrate 100-150mg/day 1993 383
MERIT-HF Metoprolol succinate 200mg od 1999 3991
US Carvediolol HF Program
Carvedilol 25-50mg bd 1996 1094
CIBIS II Bisoprolol 10mg 0d 1999 2647
COPERNICUS Carvedilol 25-50mg bd 2000 2289
Beneficial effects of Beta BlockersMERIT-HF
COPERNICUS
CIBIS II
RRR 34% RRR 35%
RRR 32%
……… and in the Elderly?SENIORS Trial (2005)
• First HF outcome trial restricted to elderly (mean age 76 yrs)
• Nebivolol (Long acting, cardioselective, vasodilating properties)SENIORS† - all cause mortality or CV hospital admission (primary outcome)1
Number of events: Nebivolol 332 (31.1%); Placebo 375 (35.3%)
Adapted from Flather et al. (2005)1
†SENIORS - Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with heart failure1. Flather MD et al. Eur Heart J 2005; 26(3): 215-225
Nebivolol initiated at 1.25mg. Target 10mg od.
Beta blockers and heart failure“all patients with heart failure should be considered for treatment with a beta blocker”
Which beta blocker, and what dose?
• Stick to beta blocker with evidence base
• 3 licensed in UK (Carvedilol, Bisoprolol & Nebivolol)
Bisoprolol (ß1 selective).
Carvedilol (Mixed α1, ß1, ß2 antag)
Nebivolol (ß1 selective & Vasodil. ? via NO)
• What dose? - “Start low, go slow”
• Aim for trial doses (or max tolerated)
• Some better than none!
Beta blockers - practical advice• Initiate slowly, in stable patients (i.e. no congestion)
• B blocker or ACEi first?
CIBIS III - Mild-moderate HFbisoprolol or enalapril firstNo difference in mortality / hospitalisation
• What if increasing congestion?
Double diuretic, if no better halve ß blocker (? stop in short term)
• What if profound fatigue/bradycardia?Unusual. Halve dose, reassess
• Inform patients:
Primary aim of Rx is to prevent worsening HF & ↑ survivalIf symptoms do improve, it can take weeks - monthsTemporary deterioration of symptoms in 20 - 30%
Angiotensin Receptor Blockers
• ACEi fail to block RAS completely
• ARB’s prevent binding of angiotensin II to type 1 receptor
Angiotensin Receptor Blockers
Chronic Heart Failure Trials
• ELITE II2000 (non inferiority to ACEi, better tolerated)
• VALHeFT 2002 (ARB + ACEi ↓ hospitalisations, but not mortality)
Post MI heart failure trials
• OPTIMAAL 2002 (ACEi better at reducing mortality)
• VALIANT 2003 (ARB similar to ACEi at reducing mortality)
CHARM AddedPatients with LVEF
<40% and treated with an ACE-inhibitor
CHARM AddedPatients with LVEF
<40% and treated with an ACE-inhibitor
CHARM Alternative Patients with LVEF <40% and ACE-
inhibitor intolerant
CHARM Alternative Patients with LVEF <40% and ACE-
inhibitor intolerant
7,601 patients with heart failure3 Individual component randomized trials with the
ARB candesartan (4 or 8 mg/day, titrated to target dose of 32 mg) or placebo
7,601 patients with heart failure3 Individual component randomized trials with the
ARB candesartan (4 or 8 mg/day, titrated to target dose of 32 mg) or placebo
CHARM Preserved Patients with LVEF
>40% with or without ACE-inhibitor
CHARM Preserved Patients with LVEF
>40% with or without ACE-inhibitor
Endpoints (follow-up minimum 2 years):Primary – Component trials: cardiovascular mortality or HF hospitalizationPrimary – Overall trial results: All-cause mortality
Endpoints (follow-up minimum 2 years):Primary – Component trials: cardiovascular mortality or HF hospitalizationPrimary – Overall trial results: All-cause mortality
CHARM Trial
Alternative Trial
0
10
20
30
40
50
candersartan placebo
%
p=0.0004
CV Mortality orCHF hospitalization
Added Trial
CV Mortality orCHF hospitalization
0
10
20
30
40
50
candersartan Std Rx + ACEi
%
p=0.011
CHARM TRIAL
Angiotensin Receptor Blockers - Summary
• ARB’s are a good alternative to ACEi in symptomatic patients intolerant to ACEi to improve morbidity and mortality
• ARB’s can be considered in combination with ACEi in patients who remain symptomatic, to reduce mortality and hospitalisation for HF (CHARM-added).
European Society of Cardiology CHF guidelines. 2005.
Heart Failure Chronic Disease ManagementFollow up interval should be maximum of 6 months
• Functional capacity – History / NYHA class / QOL / 6MW / CPX
• Assessment of fluid status – weight / L+S BP / clinical examination
• Assessment of cardiac rhythm – clinical examination, ECG
• Laboratory assessment – minimum U+E’s
• Management plan – compliance with diet, fluid, exercise, lifestyle
• Co-medications – check all medications (prescribed and OTC)
• Medical complications – angina, depression, renal failure, anaemia
Heart Failure
Specialist Nurse
Implements treatment algorithms
Continued adjustment and optimisation of treatment
Link between primary and
secondary care
Point of contact - early intervention to reduce
admission
Emotional support
Advanced HF-links with palliative care
Monitoring weights and blood tests
Promoting long term compliance
Educating patients and family -promoting self help
Patient Self Monitoring
• Patients can monitor their volume status by daily weighing and adjustment of diuretic regime.
• Requires education and support
• Patients taught to recognise early signs of decompensationand how to seek professional help
• Key role for Heart Failure Specialist Nurse (education & support)
Drugs to avoid in Heart Failure
• Anti-inflammatory medication (NSAIDS, COX 2 inhibitors)
• Class 1 antiarrhythmic agents (e.g. flecainide, lignocaine)
• Calcium channel antagonists
- Rate limiting non-dihydropyridine (verapamil, diltiazem)
- First generation dihydropyridine (nifedipine)
• Tricyclic antidepressants
• Lithium
• St Johns Wort
• Cautious use of steroids
Depression: Common and important
• Consider depression in all patients with heart failure
• Prevalence of 30% in non-hospitalised HF patients
• Diagnosis more common in those with physical symptoms and poorer physical functioning
• Depressive symptoms strongly linked with worse outcome
• But, risk/benefit of antidepressants carefully
When to Refer to a Specialist?
• Diagnostic uncertainty
• Heart failure due to valve disease
• Heart failure due to diastolic dysfunction
• Advanced heart failure (NYHA class III and IV)
• Severely impaired LV
• Patients with significant co-morbidity
• Symptomatic arrhythmia
• Women planning pregnancy
• HF no longer manageable in home setting
Cardiac Resynchronisation Therapy- an option in advanced heart failure
What is it?
• Cardiac Resynchronisation Therapy (CRT), or, BiV Pacing
• CRT first described in 1980’s
• Introduced clinically a decade later
• Routine pacemaker implant (local anaesthetic)
• With or without ICD capability
Achieving Cardiac Resynchronisation
Goal: Atrial synchronous biventricular pacing
Transvenous approach for left ventricular lead via coronary sinus
Back-up epicardial approach
Right AtrialLead
Right VentricularLead
Left VentricularLead
Why do it?• LBBB occurs in approx 30% of HF patients.
• LBBB is an independent predictor of increased mortality in HF
• Delayed LV activation (His-Purkinje system / conduction block / fibrosis)
Mechanical Dyssnychrony
Mechanical Dyssynchrony is Bad News!
• Early septal contraction → pressure low → no ejection
• Late postero-lateral contraction → paradoxical stretch (early contracting segments)
• Early / late contraction = “wasted work”
• Increased time in IVC and IVR.
• Reduced ejection / diastolic filling time
• Increased global / regional wall stress
• Increased myocardial O2 consumption
• Protracted mitral regurgitation (LV dilatation / lateral papillary muscle)
Normal LBBB
Abnormal local wall strain in LBBB
Longer
Relax
Shorter apex
base
septum
What are the benefits of CRT?
Cumulative Enrollment in CRT Randomised Trials
0
500
1000
1500
2000
2500
3000
3500
4000
1999 2000 2001 2002 2003 2004 2005
Study Results
PATH CHF
MUSTIC SR
MIRACLE
CONTAK CD
MIRACLE ICD
PATH CHF II
COMPANION
CARE HF
Proven Benefits of CRTImproves patient’s functional status• ↑ 6 min walk distance by ~ 20%• ↓ NYHA class by 0.5-0.8 points (58% v 37% ↓ by at least 1 class)• ↑ VO2 Max: by 10-15%• QOL (MLWHF) - Significantly improved (8.4 points)
Improves “pump” function• 26% ↓ in LVESV at 18 months• Significant reduction in MR regurgitant area• Approx 6% ↑ in EF
Reduces Hospitalisation• ↓ relative risk of admission for worsening CCF by 52%
Reduces cardiovascular mortality• Relative risk reduction of 40% in all cause mortality
Pre CRT Post CRT
Response to CRT
i. Viable myocardium (cannot pace scar tissue)
ii. Shot ventricular function (RV / LV)
iii. QRS is imperfect marker for mechanical dyssynchrony
iv. LV lead position
• Procedural risk (PTX, infection, lead displacement)• 5% failure to deploy LV lead• Of those successfully implanted - 30% of patients do not respond.
What’s the catch?
Who benefits from CRT?
• NYHA Class III or ambulatory Class IV
• LVEF ≤35%
• Sinus rhythm
• Optimal medical therapy
• Evidence of
QRS ≥ 150 msec
or, 120-149 msec with Echo evidence
Questions